Coding and Reimbursement Guide for PIP** (Proximal Interphalangeal) Joint Arthroplasty – 2020
Disclaimer: While Integra LifeSciences Corporation has used reasonable efforts to provide accurate coding information, this information should not be construed as providing clinical advice, dictating reimbursement policy, or substituting for the judgment of a practitioner. It is always the Provider’s responsibility to determine and submit appropriate codes, charges, and modifiers for services that are rendered. Integra LifeSciences Corporation assumes no responsibilities or liabilities for the timeliness, accuracy, and completeness of the information contained herein. Since reimbursement laws, regulations, and payor policies change frequently, it is recommended that providers consult with their payors, coding specialists, and/or legal counsel regarding coverage, coding and payment issues. It is particularly important to consult with payors for services involving Humanitarian Use Devices (such as the Pyrocarbon PIP), as payors may have specific rules concerning such devices.
ICD-10 Code Potential PCS Description MS-DRG Assignment
Arthroplasty of metacarpophalangeal and interphalangeal joint with implant 0RRW0JZ Replacement of Right Finger Phalangeal Joint with Synthetic 040-042, Substitute, Open Approach 506, 0RRX0JZ Replacement of Left Finger Phalangeal Joint with Synthetic 906, Substitute, Open Approach 957-959 Arthrotomy for removal of prosthesis without replacement, hand and finger 0RPW0JZ Removal of Synthetic Substitute from Right Finger Phalangeal Joint, 495-497. Open Approach 906, 0RPX0JZ Removal of Synthetic Substitute from Left Finger Phalangeal Joint, 957-959 Open Approach
MS- MS-DRG Medicare DRG Description National Average Payment 040 Peripheral/Cranial Nerve and Other Nervous System Procedures with $25,438.40 MCC 041 Peripheral/Cranial Nerve and Other Nervous System Procedures with $15,109.56 CC or Peripheral Neurostimulator 042 Peripheral/Cranial Nerve and Other Nervous System Procedures $12,115.03 without CC/MCC 495 Local Excision and Removal Internal Fixation Devices Except Hip and $23,358.49 Femur with MCC 496 Local Excision and Removal Internal Fixation Devices Except Hip and $12,762.27 Femur with CC 497 Local Excision and Removal Internal Fixation Devices Except Hip and $9,375.66 Femur without CC/MCC
MS- MS-DRG Medicare DRG Description National Average Payment 506 Major Thumb or Joint Procedures $9,484.93 906 Hand Procedures for Injuries $11,529.49 957 Other O.R. Procedures for Multiple Significant Trauma with MCC $47,696.52 958 Other O.R. Procedures for Multiple Significant Trauma with CC $27,029.83 959 Other O.R. Procedures for Multiple Significant Trauma without $17,573.82 CC/MCC
Hospital Outpatient/Ambulatory Surgical Center
CPT Code APC Relative 2020 Medicare 2020 Medicare Code Description Weight Base Payment Payment Rate Rate – Hospital – Ambulatory Outpatient Surgical Center 26536 Arthroplasty, 5114 74.0404 $5,981.95 $3,720.91 interphalangeal joint; with prosthetic implant, each joint 26320 Removal of implant from 5072 16.9891 $1,372.60 $576.39 finger or hand
Physician Fee Schedule
CPT Code Work 2020 National Code Description Relative Medicare Value Unit Payment Rate - Facility 26536 Arthroplasty, interphalangeal joint; with 6.56 $751.75 prosthetic implant, each joint 26320 Removal of implant from finger or hand 4.10 $361.26
HCPCS Code Code Description L8658 Interphalangeal joint spacer, silicone or equal, each L8659 Interphalangeal finger joint replacement, 2 or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon) for surgical implantation, any size
**Please note: The PyroCarbon PIP Total Joint is a Humanitarian Use Device (HUD). An HUD may only be used in facilities that have established a local institutional review board (IRB) to supervise clinical testing of devices and after an IRB has approved the use of the device to treat or diagnose the specific disease.
For assistance with coding and reimbursement, please contact our Integra Reimbursement Hotline at 1-877-444-1122, option 3, option 2, Monday to Friday, 8 am to 6 pm, or via email at [email protected]
Reference: CPT® Code Book 2020, Current Procedural Terminology (CPT) copyright 2019. American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. Fee Schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. ICD-10 PCS codes and descriptors and DRG payment groups are effective October 1, 2020.
Integra and the Integra logo are registered trademarks of Integra LifeSciences Corporation in the United States and/or other countries. ©2020 Integra LifeSciences Corporation. All rights reserved.
T – 0530293 – 1 1710274 – 1 (2020-10)